Branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms: an institutional experience on preoperative planning, intraoperative execution, and pitfalls.

Background: The purpose of this study was to evaluate the outcomes of branched endovascular aortic repair (BEVAR) in post-dissection thoracoabdominal aortic aneurysms (PD TAAAs), as well as define preoperative planning and intraoperative execution.

Methods: Patients who underwent BEVAR in PD TAAAs from 2019 to 2024 were identified using a prospectively maintained electronic database at a single, tertiary-care hospital. Patient demographics, comorbidities, indication for the procedure, anatomic and procedural details, and outcomes were retrospectively recorded.

Results: Thirty-four patients (74% male, median age 62 years) underwent BEVAR for PD TAAA. There was a high incidence of hypertension (79%) and stage III-V chronic kidney disease (41%). Prior aortic surgery was prevalent in the majority (62%) of patients, with an open (53%) and/or endovascular (35%) approach. BEVAR was commonly performed for asymptomatic PD-TAAA without rupture (71%). Target vessels (TV) arising from the false lumen (FL) and dissected TVs occurred in 32% and 11%, respectively. The majority underwent staged repair by an open (15%) and/or endovascular (47%) approach, most commonly zone 2 (24%) or 3 (15%) thoracic endovascular aortic repair (TEVAR). The off-the-shelf t-Branch (Cook Medical) was used in 24 (70%) patients. The proximal and distal landing zones were in prior/staged TEVAR (71%) and in native infrarenal aorta (65%), respectively. The bridging stent-graft was most commonly balloon-expandable (70%), including hybrid stenting with self-expandable stent-grafts. Adjunctive FL management and prophylactic embolization of type II endoleaks were performed in 56% and 79%, respectively. Technical success was 94%. Postoperative complications were most commonly self-limited acute kidney injury (9%); there was no episodes of spinal cord ischemia. There was a 30-day mortality of 6%. Thirty-day reinterventions were 3% (N.=4, 130 target vessels) for TV-related instability and 6% (N.=2, 34 patients) for FL perfusion. Based on a median follow-up of 18 months, primary and primary-assisted patency of the TV were 94% and 99%, respectively. Midterm reinterventions were 6% for TV-related instability and 35% for FL perfusion. There were no surgical conversions.

Conclusions: BEVAR can be performed with high technical success in PD TAAAs. However, secondary interventions for TV instability and continued FL perfusion are frequent; thus, close follow-up is mandatory.